The nurse is preparing to administer medications for an eight-month-old infant with heart failure. The infant has a blood pressure of 114/66 mm Hg, apical pulse of 88 beats/minute, and respirations of 30 breaths/minute.
Which medication should the nurse withhold until the healthcare provider is notified?
Digoxin.
Furosemide.
Hydralazine.
Enalapril.
The Correct Answer is A
For an eight-month-old infant with heart failure, the nurse should withhold digoxin if the infant's apical pulse is less than 90 beats/minute and notify the healthcare provider. In this case, the infant's apical pulse is 88 beats/minute, so the nurse should withhold the digoxin and notify the healthcare provider.
Furosemide ( B), hydralazine (C), and enalapril (D) do not have specific parameters for withholding based on the infant's vital signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should prepare the mother for a sweat-chloride test to screen for cystic fibrosis (CF). A sweat- chloride test measures the amount of chloride in the sweat and is used to diagnose CF. CF is a genetic disorder that can cause the body to produce thick, sticky mucus that can clog the lungs and pancreas. One of the symptoms of CF is salty-tasting skin due to an increased amount of salt in the sweat. The other options (B, C, and D) are not standard diagnostic tests for screening for CF.
Correct Answer is B
Explanation
Answer: (B) Counsel the client about the risks and benefits of using oral contraceptives.
Rationale:
(A) Encourage the client to discuss her need for contraceptives with her parents: Encouraging open communication with parents is important, but this action might not be the most appropriate in this context. The client has expressed a desire for confidentiality, and respecting her autonomy is essential, particularly when it comes to sensitive topics like sexual health.
(B) Counsel the client about the risks and benefits of using oral contraceptives: Providing counseling about the risks and benefits of oral contraceptives is the most appropriate action. It ensures the client is informed and able to make a decision that is right for her health and circumstances. The nurse can also discuss other contraceptive options and provide education on safe sex practices. This approach respects the client's autonomy and privacy while ensuring she receives the necessary information to make an informed choice.
(C) Explain that she needs parental approval to receive contraceptives: In many areas, adolescents have the right to obtain contraceptives without parental consent. Requiring parental approval might not only be legally incorrect but could also discourage the client from seeking necessary healthcare, potentially putting her at risk.
(D) Tell the client how to receive a variety of free oral contraceptives from the clinic: While providing information about accessing contraceptives is helpful, this option alone does not address the need for thorough counseling about the risks and benefits. It's important to ensure that the client understands the implications of using oral contraceptives and has the opportunity to ask questions and receive guidance tailored to her individual needs.
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